Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor.
Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor.
JAMA Netw Open. 2020 Feb 5;3(2):e1920548. doi: 10.1001/jamanetworkopen.2019.20548.
Management of antithrombotic medications presents a challenge for many clinicians and patients before procedures. Anticoagulation clinic involvement may improve preprocedure coordination, satisfaction on the part of patients and clinicians, last-minute procedure cancellations, and patient safety.
To assess the implementation of an electronic medical record (EMR) best practice alert (BPA) and anticoagulation clinic referral process to assist with management of antithrombotic medication before gastrointestinal endoscopic procedures.
DESIGN, SETTING, AND PARTICIPANTS: This multimodal evaluation of a quality improvement intervention using EMRs and survey data included patients using oral antithrombotic medications who were scheduled for elective gastrointestinal endoscopic procedures at an academic medical center along with the clinicians who ordered these procedures. Data were collected from November 1, 2017, through December 19, 2018. Data were analyzed in September 2019.
Following a multidisciplinary intervention, a BPA and referral process for periprocedural antithrombotic medication management was implemented in November 2017.
The following implementation outcomes were assessed through EMR review and surveys through December 2018: use of BPAs, patient and clinician satisfaction with preprocedure anticoagulation management, procedure cancelation rates, reach, and spread by patient and clinician characteristics. Multilevel logistic regression was used to estimate variance in BPA use at the clinician level.
A total of 2082 patients (mean [SD] age, 64.1 [11.9] years) and 144 clinicians were included in the analysis. The BPA was used broadly across the health system, resulting in anticoagulation clinic referral for 1389 patients (66.7%). Referral was more common for patients using anticoagulant vs antiplatelet medications (1041 of 1524 [68.3%] vs 346 of 556 [62.2%]; adjusted odds ratio [aOR], 1.51; 95% CI, 1.15-1.98) and for procedures ordered by gastroenterologists vs primary care clinicians (933 of 1241 [75.2%] vs 365 of 618 [59.1%]; aOR, 2.15; 95% CI, 1.46-3.17). Individual clinician behavior patterns explained 26.5% (95% CI, 18.7%-36.1%) of variation in anticoagulation clinic referrals. Implementation of the intervention was associated with high patient satisfaction and improvements in multidimensional measures of clinician satisfaction (clinician response rate, 44.2% [144 of 326]). In multivariable analysis, the odds of altered or canceled procedures because of medication mismanagement declined after implementation (8 of 50 [16.0%] vs 1 of 52 [1.9%]; aOR, 0.11; 95% CI, 0.01-0.96; P = .02).
A newly implemented BPA and anticoagulation clinic referral process was broadly adopted and used, had high satisfaction by patients and clinicians, and was associated with fewer disruptions to planned procedures caused by medication mismanagement.
在进行手术前，许多临床医生和患者在使用抗血栓药物方面都面临着挑战。抗凝门诊的参与可以改善术前协调、患者和临床医生的满意度、最后一刻的手术取消以及患者的安全。
评估电子病历（EMR）最佳实践警报（BPA）和抗凝门诊转诊流程的实施情况，以协助管理胃肠内镜检查前的抗血栓药物。
设计、地点和参与者：本研究采用多模式方法，使用 EMR 和调查数据对质量改进干预措施进行了评估，包括在学术医疗中心计划进行择期胃肠内镜检查的使用口服抗血栓药物的患者，以及为这些检查开处方的临床医生。数据于 2017 年 11 月 1 日至 2018 年 12 月 19 日收集。数据分析于 2019 年 9 月进行。
在多学科干预之后，于 2017 年 11 月实施了围手术期抗血栓药物管理的 BPA 和转诊流程。
通过 EMR 审查和调查，评估了以下实施结果：使用 BPA 的情况、患者和临床医生对术前抗凝管理的满意度、手术取消率、患者和临床医生的覆盖率和传播率。采用多水平逻辑回归估计了医生水平上 BPA 使用的差异。
共有 2082 名患者（平均[标准差]年龄，64.1[11.9]岁）和 144 名临床医生纳入分析。该 BPA 在整个医疗系统中广泛使用，导致 1389 名患者（66.7%）被转诊至抗凝门诊。与使用抗血小板药物的患者相比（1041 例/1524 例[68.3%]比 346 例/556 例[62.2%]；调整后的优势比[OR]，1.51；95%置信区间[CI]，1.15-1.98）和与胃肠病医生相比（933 例/1241 例[75.2%]比 365 例/618 例[59.1%]；OR，2.15；95%CI，1.46-3.17），使用抗凝药物的患者更常被转诊至抗凝门诊。个体临床医生的行为模式解释了抗凝门诊转诊差异的 26.5%（95%CI，18.7%-36.1%）。干预措施的实施与患者满意度的提高以及临床医生满意度的多维指标的改善相关（临床医生的回复率为 44.2%[144 例/326 例]）。多变量分析显示，在实施后，由于药物管理不当而改变或取消手术的几率降低（50 例中的 8 例[16.0%]比 52 例中的 1 例[1.9%]；OR，0.11；95%CI，0.01-0.96；P = .02）。
新实施的 BPA 和抗凝门诊转诊流程得到了广泛采用和使用，患者和临床医生的满意度都很高，并且与因药物管理不当而导致的计划手术中断减少有关。
